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_96  Ether-oil  rectal  ane 


/F/'HER-OIL     RECTAL     ANES- 
THESIA;    SOME     THEORET- 
L^  CONSIDERATIONS. 

BT 

H.    CLIFTON    LUKE,    M.D., 

NEW  YORK: 
Anesthetist  to  St.   Luke's  Hospital. 


REPRINTED  FROM 
THE 

MEDICAL    RECORD 

May  9,  1914 


WILLIAM  WOOD  &  COMPANY 

NEW   YORK 


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ETHER-OIL     RECTAL     ANESTHESIA;     SOME 
THEORETICAL   CONSIDERATIONS. 

By  H.  CLIFTON  LUKE,  M.D., 

NEW   YORK. 
ANESTHETIST    TO    ST.    LUKE'S    HOSPITAL. 

The  administration  of  ether  per  rectum  has  once 
more  taken  on  a  certain  degree  of  popularity,  the 
present  advocates  of  the  method  using  it  in  the 
form  of  an  oil-ether  enema.  The  results  here,  in 
the  hands  of  experienced  anesthetists,  have  been 
variable,  some  praising,  others  disfavoring  the 
method.  There  are  some  theoretical  objections, 
hov^ever,  to  the  procedure,  and  it  is  the  purpose  of 
these  remarks  to  deal  with  the  subject  chiefly  from 
this  viewpoint. 

The  usual  technique,  omitting  special  refine- 
ments, is  in  brief  as  follows:  Effort  is  made  to 
thoroughly  cleanse  the  intestinal  tract,  especially 
the  large  intestine,  beforehand;  a  hypodermic  in- 
jection of  morphine,  sometimes  in  combination 
with  atropine  or  hyoscine,  is  usuallj^  given  one- 
half  hour  before  injecting  the  ether;  the  mixture 
of  ether  and  oil  (olive  oil  being  mostly  used),  con- 
taining about  seventy-five  per  cent,  ether  in  adult 
cases,  is  given  in  a  single  dose  of  six  to  eight  ounces 
by  volume  very   slowly  through   a   small  catheter 

Copyright,  William  Wood  &  Company. 
1 


into  the  lower  bowel.  This  is  injected  about  thirty 
minutes  before  operation,  the  patient  being  in  bed 
until  the  unconscious  state  is  reached.  If  surgical 
anesthesia  is  not  obtained  in  thirty  to  forty  min- 
utes, more  ether  is  injected  per  rectum  or  admin- 
istered for  a  brief  time  by  inhalation. 

Can  we  say  that  this  method  is  founded  on  a 
good  scientific  basis?  In  other  words,  is  it  exact 
or  accurate?  The  administration  of  ether,  to  be 
exact  within  a  reasonable  meaning  of  the  term, 
should  have  the  dosage,  or  amount  administered, 
under  direct  control,  which  in  turn  exercises  a 
fairly  definite  influence  on  the  dose  or  amount  ac- 
tually absorbed.  This  fundamental  requirement 
does  not  appear  to  be  fulfilled  here:  (1)  because 
the  entire  dosage  is  estimated,  and  placed  in  the  in- 
testine for  absorption  before  essential  information 
is  acquired  by  the  anesthetist  regarding,  (a)  length 
of  time  the  operation  will  take  (which  is  often 
impossible  to  know),  (b)  the  patient's  resistance, 
susceptibility,  or  even  special  idiosyncrasy  to  the 
drug;  (2)  because  a  portion  or  all  of  the  mixture 
may  be  expelled  and  lost,  in  which  event  an  estima- 
tion of  the  amount  still  retained  would  be  largely 
guesswork;  (3)  since  there  is  also  a  small  chance 
of  error  if  the  mixture  is  given  in  the  usual  man- 
ner by  pouring  through  an  open-topped  funnel ; 
over  a  period  of  five  minutes  material  loss  by  evap- 
oration could  occur. 

Then,  in  reference  to  the  important  question  of 
dose  there  also  appears  to  be  considerable  uncer- 
tainty, and  the  reasons  for  this  are:  (1)  the  influ- 
ence of  the  inaccurate  dosage  as  pointed  out  above ; 
(2)  the  patient's  age  would  have  a  bearing  on  the 
rate  of  absorption,  a  given  quantity  of  ether  prob- 
ably entering  the  blood  stream  in  young  people,  in 


considerable  less  time  than  it -would  in  those  past 
middle  life;  (3)  position  of  the  solution  in  the 
large  intestine  has,  undoubtedly,  a  marked  influ- 
ence on  the  rate  of  absorption.  It  is  impossible  to 
know  just  how  high  it  goes  in  any  particular  case, 
which  adds  to  the  uncertainty;  but  it  seems  highly 
probable  that  in  some  cases  reverse  persistalsis  may 
take  place  carrying  the  mixture  into  the  cecum, 
making  its  recovery,  in  case  of  over  dosage,  prac- 
tically impossible  and  materially  increasing  the  rate 
of  absorption.  Practical  proof  of  this  possibility 
is  shown  in  Stewart's  case  where  a  lead  pencil,  in- 
serted into  the  rectum,  soon  reached  the  cecum 
from  which  it  had  to  be  removed.  Also  in  Chapin's 
work  on  babies  where  ic-ray  examinations  showed, 
after  low  injections  of  bismuth  solution,  that  this 
material  practically  always  reached  the  cecum.  Le- 
Wald  further  states  that  low  rectal  injections  of 
bismuth  solution  pass  into  the  ileum  in  about  10 
per  cent,  of  cases  due  to  incompetency  of  the  ileo- 
cecal valve,  and  that  in  over  90  per  cent,  the  solu- 
tion reaches  the  cecum.  That  this  factor  has  an 
important  practical  side  is  evidenced  by  the  fact 
that  the  Trendelenburg  position  (the  necessity  for 
which  cannot  always  be  foretold)  is  considered  by 
some  to  contraindicate  the  use  of  the  method;  (4) 
pathological  conditions  of  the  rectum,  sigmoid,  or 
descending  colon  might  strongly  retard  or  increase 
the  absorption;  (5)  an  excessive  amount  of  ether 
is  probably  absorbed  (a)  because  the  induction 
period  is  prolonged  (frequently  requiring  one-half 
to  three-quarters  of  an  hour),  which  is  due  to  the 
slow  absorption,  the  mixture  having  not  yet  reached 
a  very  high  position  in  the  intestine.  Likewise,  in 
the  administration  by  inhalation  of  vapors  of  insuf- 
ficient  strength,    patients    can   be    given    excessive 


quantities  of  ether  without  obtaining  surgical  anes- 
thesia, whereas  a  much  smaller  amount  expediently 
administered  gives  the  desired  result  in  very  much 
less  time;  (6)  since  olive  oil  is  said  to  hold  the 
ether  in  close  combination  and  give  it  up  slowly, 
absorption  may  continue  for  a  considerable  time 
after  operation  and  delay  the  recovery,  as  there  is 
no  way  of  determining  how  much  of  the  mixture 
still  remains  in  the  intestine  after  the  passage  of 
tubes  or  irrigation;  (6)  the  varying  amount  of  in- 
testinal surface  exposed  to  the  action  of  the  mix- 
ture; (7)  the  claim  for  even  and  constant  evapora- 
tion of  ether  from  the  mixture  would  hardly  seem 
valid,  for  many  surgical  cases  run  more  or  less 
severe  temperatures,  the  influence  of  which  toward 
increasing  the  absorption  must  be  considerable  in 
view  of  the  low  boiling  point  of  ether. 

Among  other  theoretical  objections  would  be  the 
possibility  of  a  special  form  of  toxemia  from  ab- 
sorption; for  a  powerful  solvent  is  placed  im- 
mediately before  it  is  to  enter  the  blood  stream, 
in  direct  contact  with  a  variable  amount  of  highly 
toxic  intestinal  material.  Does  it  not  seem  possible, 
therefore,  that  definite  quantities  of  toxines  may 
thus  be  assisted  to  re-enter  the  circulation?  If 
so  an  extra  burden  is  placed  upon  the  eliminative 
functions,  and  the  vitality  of  the  patient  suffers 
accordingly.  Furthermore,  the  mode  of  reaching 
the  vital  centers  by  the  anesthetic  is  circuitous,  it 
having  to  first  enter  the  venous  blood  and  be  con- 
ducted through  the  portal  system  before  reaching 
the  right  heart  and  lungs.  It  would  seem  desirable 
to  introduce  an  anesthetic  into  as  clean  and  acces- 
sible a  part  of  the  body  as  possible  where  it  may 
immediately  enter  the  arterial  circulation,  and  reach 
the  nerve  centers  by  the  most  direct  course.     The 


pulmonary  route  fully  meets  these  requirements. 
The  routine  use  of  morphine  is  said  to  be  necessary 
with  the  rectal  method,  which  has  the  disadvantage 
of  depressing  the  respiratory  center  and  locking  up 
the  secretions;  objections  which  here  seem  to  have 
special  import.  Furthermore,  the  respiratory  cen- 
ter cannot  utilize  its  protective  function  against 
over-dosage  in  the  rectal  method,  as  it  may  in  the 
inhalation  methods  where  the  administration  is 
under  direct  control,  because  with  the  former  de- 
pressed and  superficial  breathing  does  not  auto- 
matically lessen  the  intake  of  ether,  since  the 
dosage  is  independent  of  this  protection.  In  fact, 
the  opposite  appears  to  occur  since  the  more  ether 
absorbed  the  greater  the  respiratory  depression 
and  the  less  the  respiratory  interchange,  resulting 
in  retarded  elimination  with  consequent  cumulative 
ether  effect.  Lastly,  that  a  normal  anus  should 
often  be  severely  irritated  in  this  procedure  seems 
only  natural  to  expect,  and  if  a  fissure  or  hemor- 
rhoids were  present  the  outcome  might  be  quite 
serious. 

The  advantages  of  the  oil-ether  method  outside 
of  its  simplicity  seem  to  be  more  apparent  than 
real.  In  fact,  with  the  possible  exception  of  selected 
cases  of  bronchoscopy,  it  is  difficult  to  see  any  indi- 
cation for  its  use  that  cannot  be  as  well  and  prob- 
ably more  safely  met  by  the  modern  pulmonary 
methods.'  Its  chief  advantages  are  said  to  be  found 
in  surgery  of  the  head  and  neck,  since  there  is  no 
hindrance  to  the  operator  in  the  way  of  anesthetic 
apparatus.  The  ordinary  intratracheal  catheter 
could  not  inconvenience  the  surgeon  much,  either, 
and  the  intratracheal  method  offers  a  much  greater 
margin  of  safety  to  the  patient,  especially  in  sur- 
gery about  the  face,  mouth,  and  neck,  for  several 


reasons;  first,  because  it  affords  an  efficient  pro- 
tection against  pneumonia  of  the  aspiration  type; 
second,  because  it  provides  a  delicate  and  even  con- 
trol of  the  ether  dosage,  enabling  one  to  maintain 
a  very  light  narcosis,  and  establish  the  coughing 
reflex  at  the  close  of  the  operation ;  third,  it  further 
conserves  the  patient's  vitality  by  providing  perfect 
aeration,  thus  obviating  any  possibility  of  ob- 
structed breathing  or  necessity  of  packing  off  the 
throat,  with  the  use  of  nasal  tubes.  In  our  series 
of  intratracheal  anesthesias  we  note  that  it  has 
been  employed  forty  times  in  operations  about  the 
head  and  neck  (over  half  of  which  were  resections 
of  the  upper  and  lower  jaw  and  tongue  and  plastic 
procedures),  without  a  single  case  of  pneumonia 
or  anesthetic  complication,  except  one  case  of  sub- 
cutaneous emphysema,"  which  recovered.  On  the 
other  hand,  the  only  jaw  resection  we  have  done 
with  the  oil-ether  method  died  with  an  aspiration 
type  of  pneumonia  twenty-two  hours  after  opera- 
tion. This  patient,  a  fairly  vigorous  man  of  about 
fifty  years,  really  never  recovered  from  the  anes- 
thetic, and  was  in  a  most  profound  state  of  narcosis 
for  nearly  six  hours.  Six  ounces  of  ether  and  two 
ounces  of  olive  oil  were  administered  in  the  usual 
manner,  and  both  before  and  after  the  operation 
was  completed  the  colon  was  repeatedly  irrigated 
without  apparent  benefit.  This  case  is  cited  here 
simply  to  point  out  one  of  the  method's  shortcom- 
ings in  this  kind  of  work.  Another  advantage  is 
said  to  be  the  very  quiet  type  of  anesthesia  pro- 
duced, which  is  common  in  any  method  where 
there  is  a  free  air-way.  But  it  must  be  remem- 
bered that  most  patients  profoundly  under  ether 
behave  in  this  manner.  In  a  good  ether  anesthesia 
the  depth  of  narcosis  is  intelligently  and  gradually 


varied  to  meet  the  operative  requirements  during 
the  different  stages  of  the  operation.  This  would 
appear  to  be  possible  only  when  the  dosage  is  under 
direct  and  definite  control. 

In  closing  these  remarks  it  may  be  well  to  men- 
tion some  of  the  undesirable  clinical  features  which 
must  certainly  be  looked  for  in  a  method  involving 
so  many  theoretical  objections.  The  following  are 
offered  for  consideration:  (1)  The  rather  ex- 
haustive and  unpleasant  experience  accompanying 
any  special  rectal  preparation,  as  required  here; 
(2)  the  occasional  necessity  and  inconvenience  of 
preliminary  and  subsequent  proctoscopic  examina- 
tions, as  a  matter  of  safety  and  caution;  (3)  oc- 
currence during  the  induction  period  of  cramps, 
with  distressing  sensations  of  fullness  and  pres- 
sure in  the  lower  bowel,  accompanied  by  desire  for 
stool;  varying  degrees  of  anal  irritation  occuring 
early  or  late;  (4)  prolonged  induction  stage  with 
frequent  necessary  recourse  to  the  inhalation 
method;  (5)  any  time  after  the  first  fifteen  or 
twenty  minutes'  respiratory  depression  may  rather 
suddenly  or  slowly  appear,  followed  by  arrested 
breathing,  loss  of  muscular  tone  and  diluted  pupils, 
with  the  possibility  of  fatal  syncope  supervening; 
(6)  the  occurrence  of  mild  to  very  severe  grades  of 
proctitis  and  colitis,  these  complications  appearing 
in  more  aggravated  forms  where  any  pre-existent 
pathological  condition  is  present;  (7)  delayed  re- 
covery, which  may  be  prolonged  for  many  hours; 
(8)  increased  toxemia,  dependent  on  a  number  of 
factors  already  discussed  and  which  has  recently 
been  pointed  out  by  Coburn.^ 

We  believe  that  any  method  of  administering 
ether  to  children,  old  people,  or  cases  at  any  age 
where  there  is  more  than  the  average  risk,  that 


does  not  provide  for  immediate  and  definite  control 
at  all  times,  is  certainly  hazardous.  It  is  also  con- 
tended that  any  principle  of  administration  which 
attempts  to  figure  the  dosage  of  ether  on  the  basis 
of  body  weight  is  unscientific  and  impractical;  be- 
cause the  influence  and  importance  of  personal  equa- 
tion in  drug  dosage  is  a  matter  of  every  day  ex- 
perience, and  in  operative  work  there  are  a  number 
of  other  factors  which  always  play  an  important 
role  in  the  amount  of  anesthetic  required. 

To  point  out  some  of  the  theoretical  shortcomings 
of  a  method  does  not  necessarily  condemn  that  pro- 
cedure; but  by  presenting  the  possibility  of  unde- 
sirable or  dangerous  symptoms  and  results,  it  may 
help  to  temper  with  conservatism  the  light-hearted 
manner  in  which  many  of  these  new  propositions 
are  taken  up,  especially  by  those  who  are  inex- 
perienced. 

REFERENCES. 

1.  Janeway:  "Intratracheal  Anesthesia  from  the 
Standpoint  of  the  Nose,  Throat,  and  Oral  Surgeon," 
Laryngoscope,  1913,  XXIII,  1082. 

2.  Luke:  Surg.,  Gynec,  and  Obst,  1913,  XVI,  204. 

3.  Coburn:  "Increase  in  Toxication  of  Ether  Ijy  New 
Methods  of  Administration,  Jour,  of  A.  M.  A.,  1914, 
LXII,  364. 

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American   Medical   AssoclaLon 

Southern  S'lrglcal  and  OynecoliiigicAl 
AsaocJatloii .......',.. 

Now  York  Academy  of  kledlclne. ..... 

The   Western    Surgical   Association.,*, 

Connecticut  State   Medical  Society. ^^ 
•■  MEDICOLEGAL  NOTES. 

Matpraiitlce — Recoonsiblllty  for  Op- 
eration Corducteu  by  Another 

Finger  Print  Impr^esslons  as  Evidence 
—Tftstainentary  Capacity — Effect  of 
Disease — Denliet  Not  a  Surgeon 
Within  Siftlute  on  Privileged  Com- 
munlcetions  —  Scope  cf  Privltnrcd 
Communications  —  Municipality's 
Power  to  Contract  for  Medical  Ser- 
vices— Expert  Svlder.ce  in  Mutiler 
Case 

STATE  MEDICAL  LICENSING  BOARDS. 

State  Board  Examination  Questions— 
Ohio  State  Medical    Board 

Answers  to  State  Board  Bxamlaatlon 
Ouesticna  —  Ohio  State  Medical 
Board 

AdvanciMl  Reijulrvmente  of  Prdtm- 
Ir.Try    Education. -'... 

Bulletin  of  Approaching  ExaminationB 
NEW   INSTRUMENTS. 

A  Needle  Holder  for  the  Intravenous 
Administration     of     .•^alvarsan.       By 
Hubert  V    Guile.  M.D.  New  Yorlt. 
MEDICAL    ITEM& 

Contagious  Diseases— Weakly  8t4t«  • 
mpnt— .Seallh  .Reports ,,      _^ 

OIRECTORY        OF        NATIONAL        AM0 
*    STATE,  MEDICAL    SOCIETIES. 

.'■■■■  Ir  ■      ■     ■         ■  .  I.     .W'WJ 


JUST    PVBt,lSttED 


URGENT  SURGERY 


By  FfiLIX  LEJARS 
Volomc  Tw»— Th«  Ml.  witi  20  Full-page  Plat*?  and  «i5«  Illustrations 


Pnce  muslin.  $U.05.  haUmOT>:co,  SieOW 


AN  INDEX  OF  TREATMENT 

BY  VARIOUS  WRITERS  Edited  by 

ROBERT  HUTCHISON.  M.D..  F  R.C.P .  and  H  STANSFIBLD  COLLIER.  P  R.C.S 

2lebistt>  (0  Cenferm  tuitb  Smtrican  l^rartite  bp 

WARREN  COLEMAN,  M.D 

Sinfe  KdltiMl,  R.TUU4  and  Enlarged  Octaves  lOt?  pages,  illuairatcd.     Extra  MoUiBi  f  6.00  b«t.     Hal(-mor»cce,  t7.M  not 


RIUIAH  WOOD  XM  CeUPAK?.  Hetfieal  Pobiisbers 


.    .    SI  Filth  ivesBe.  New  York 

6>lfr«t  «  (O  r<*kCWR  .i  Ktm  Vuk  t,  Stcnt-Clta  MOW 


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